Your first patient of the day is a successful person in the community. She is admired by her friends and colleagues, respected by her coworkers and staff, and loved by her family. She came in to see you today because she is tired and restless and has multiple minor aches and pains. She also doesn't have the energy that she had a few years ago. On your evaluation you find that she is working many more hours than she used to, she is not spending time with her family, and although she understands exercise and healthy nutrition, her diet and exercise program is somewhat lacking. On further questioning, you gain a sense that she is type A with modest anxiety. She has a pressure to succeed and a need to be seen by others as successful and caring. This leads her to overwork, lack in selfrcare, and lack in connection with others. Does this patient sound familiar? This patient is representative of most midcareer physicians. What would you recommend to this person? After ruling out any significant underlying disorder, it is likely that you would recommend a lifestyle change program, including the following: Optimizing physical well-being Optimizing emotional well-being Optimizing mental well-being Optimizing spiritual well-being The first step is to realize that this patient is worth the effort! Why do all this work? Maybe you feel that you don't deserve to take the time needed to be healthy. Maybe you feel that that would be a self-centered approach to life and medicine. To put it bluntly, dead doctors serve no one! If you are to be a healer, you must begin the process of healing yourself, learning from your mistakes, and then teaching from this experience of trial and one, do one, teach one." It is no use walking anp•.'here to preach unless our walking is preaching. St. Francis of Assisi The physician is a teacher. The Latin root Of the word doctor translates to "teacher." We are teachers of infor- mation. Ideally, we serve as a stable guide and resource to our patients and community, and we teach by example. Nowhere in medicine is the concept of teaching by example more important than in the practice of integrative/holistic medicine, where life balance moves the individual toward the goal of optimal health. Our personal presence and sense Of self affects our interactions with our patients and also affects our
patienfi outcomes. If we are agitated, rushed, and acting out type A tendencies in our office, our patients will see this and have no apparent resource for managing these issues themselves as they attempt to modify their lives. If we can be self-aware and working on these issues ourselves, then we can serve as teachers to our patients, our partners in health. To put the world right in Order, we must first put the nation in order; to put the nation in order, we must first put the family in order; to put the family in order, we must first cultivate our personal life; we must first set our hearts right. Confuci us Creating your Own Health Plan How can we physicians gain a reasonable sense of life balance and therefore be better teachers to our patients? First, one must realize that life balance is a process, not a goal. One day you may feel as if you've "got it" and then something unexpected occurs, throwing you into imbalance once more. Perfection is not the goal either. The belief that one can be in perfect health, without medical or evaluated; however, a few studies have been done. We smoke less, exercise more, and eat healthier than our patients, yet our overall mortality is not much better than any other professional group. Our per-capita rates Of heart disease. depression, and stroke are higher than any other working group.'._. Although earlier data on physician mortality are a bit frightening, more recent data suggest that our overall mortality is improving. We now live roughly 5 years longer than other professionals. When put in perspective of our better exercise, nonsmoking, leaner body mass, our self-care knowledge base. and healthy eating, this doesn't appear to be a substantial difference. • One of the missing health pieces for us may be our high rate of stress and depression, which enhances cardiovascular mortality.' As most readers will be aware of the physical aspects of life and health, I will not say much about them here except to mention that they include nutrition, exercise, body work, stretching, and physical pleasure. One part of physical well- being that deserves special mention is sleep. Jt is reasonable and important to get enough sleep on a near-daily basis. Without this, life balance becomes difficult, and our health suffers as well. Physicians are often sleep deprived.
then Jomething unexpected occurs, throwing you into imbalance once more. Perfection is not the goal either. The belief that one can be in perfect health, without medical or emotional issues, at all times, throughout life will lead to disappointment. True balance involves trying and failing, learning from error, and finding new ways of enhancing well-being. The process Of balance includes paying attention to the four key areas of your personal life and development: (l) the physical, (2) the emotional, (3) the mental, and (4) the spiritual. The more balanced we are, the healthier our relationships will be. If we live a life of healthy relationships where our emotional needs are met, we can approach our work with our grace, humor, and values intact. The creation of life balance brings us closer to our own optimal health. The American Board of Holistic Medicine defines optimal health as The conscious pursuit of the highest level of functioning and balance of the physical, environmental, mental, emotional, social, and spiritual aspects of human experience, resulting in a dynamic state of being fully alive. This creates a condition of well-being regardless of the presence or absence of disease. With this in Copyfish Our Emotional Well-Being Our emotional stress or distress is one Of the primary causes of our life imbalance. Conversely, emotional well-being is one of the strongest antidotes to life imbalance. Much of our emotional imbalance Can be rooted in Our personality structure. It is often less about what we are doing than how
The conscious pursuit of the highest level of functioning and balance of the physical, environmental, mental, emotional, social, and spiritual aspects of human experience, resulting in a dynamic state of being fully alive. This creates a condition ofwell-being regardless Of the presence or absence of disease. With this in mind, let's proceed to look at the four key areas Of life balance in an average physiciar* life. Our Physical Well-Being What is the state of physical well-being Statistics on physician health are only for physicians? recently being Well—Being Our emotional stress or distress is one of the primary causes of our life imbalance. Conversely, emotional well-being is one of the strongest antidotes to life imbalance. Much of our emotional imbalance can be rooted in our personality structure. It is often less about what we are doing than how we are doing it. This personality structure is well in place before our first day of medical school, and some of the more problematic aspects of this structure are made worse through our medical training. The psychological make-up of a physician-to-be is most interesting and Often problematic. We are people oriented, intelligent, caring, inquisitive individuals. This is a natural fit with our intended careers. We are also type A, perfectionist, and competitive. Although these are not considered, by most, to be positive attributes, it would seem to be extremely difficult to survive the current structure of medical school and postgraduate training without these qualities. We also tend toward social isolation. Many Of us are shy or quiet and a bit "nerdy" as well.
Individuals attracted to a career in medicine also tend to be safety seeking or change averse. This was one of the attractions of medicine 20 years ago. Medicine was a stable career path. We now know this to be untrue; medicine has changed dramatically over the last few decades and Will continue to do so. For the change averse, change increases anxiety. •rhis has been a daily reality for many physicians over the past 20 years. Our awareness Of change does not mean that we have learned flexibility. Our inflexibility and resistance to change leaves us frustrated and anxious about our futures. Medical Training Our type A, perfectionist, and «»mpetitive attributes are enhanced during our schooling/training process. Fear of failure enhances type A and competitive behaviors. Fear Of error enhances perfectionism to obsessive levels (yes, we are dealing With serious issues. but obsession is healthy for no one). Social isolation is increased with our long hours and exhaustion. And learned emotional dissociation, to be objective, tends to shut down our compassion. By the time we are ready to enter practice, we are exhausted. isolated from family and friends, in debt, nontrusting, egocentric (the expression of insecurity), and emotionally dissociated (numb). This does not make us healthy physicians, not be true tomorrow. This brings average hit rate down to 50%. If you add the fact that we are fallible and that there are variances for response to treatments, you may be correct to Of the time. Don't feel bad—in baseball, the greats have a batting average Of less than 40%, so you are still up there! Where this becomes a problem for us is that we chastise ourselves for these errors. We worry and hold anxiety about them for years. I still feel anxious about misdiagnosing a patient With testicular cancer that fortunately was caught by a colleague. That was 13 years ago! Generally, we have no one to discuss these mistakes With. We are afraid to talk to our coworkers because we don't want to be seen as imperfect and We know We'll be judged. We don't want to trouble our spouses With this informa- tion in that they "may not understand" or we may fear their iudgment as well. Often, What is behind this is our own insecurity. The underlying question is, are we good enough? If wc can't be imperfect, this disallows patients their own imperfection, and they feel to less than human. Imperfections. our own flaws, are sometimes our greatest teaching tools. Where did this perfectionism come from? Much of this behavior is learned from our parents. In a personal com- munication, Rachael Naomi Remen, a wonderful physician and author. described a scene from her childhood. She recalled coming home to her father With a test score Of 98 and excitedly telling him about it. His response was, "What
the teachers of optimal health. Perfectionism Why bother to look at this issue? Isn't it better to be perfect? Expecting perfection is a fallacy when one is living a life Of constant change, working With a population that Will sometimes follow your instructions in a system that can only sometimes fill your needs and the patient' needs and teaching a science filled with gray mnes of understanding. "Good enough" may be all you get. Beyond this, "perfect" is truly an artificial construct. R•rfectionism is extremely common among our colleagues. It is excused or even supported because we often deal with issues. This fosters the belief that mistakes are inexcusable. If a physician is imperfect, he or she is a bad physician. Yet we are all fallible; we all make mistakes, as do the rest of the humans on the planet. This paradox can create significant stress for us. If you see 25 patients daily, 5 days a week (for many Of us, it's more), 48 weeks per year for 30 years, that' 300,000 clinical decisions made. (How many of you perfectionists checked my math?) NOW When you consider that we usually multitask and make clinical decisions outside of work as well, the number ows substantiallv. With this in mind what happened to the Other two points?" encapsu dynamic Of perfection perfectly! As children we want to please our parents. Depending on the existing relationship, this need can be driven by seeking love and support, or it may be driven by avoiding discomfort. Our parent may hold lofty goals and expectations for us and often believe that it is in our best interest to "go for the gold." The belief that shooting for the stars will facilitate our doing well even if we fall slightly short Of this goal is prevalent in our country. On a superficial level this may seem viable; however, look at the effect of the simple interaction described earlier on a young child. The child is excited by her achievement. If she receives support from her father, she would be motivated to continue this good work. as it serves her goal of feeling loved and validated. She vmuld develop a healthy self-esteem and would continue to learn without anxiety. She would also be likely to have greater self-confidence and creativity. She would then bring this into other relationships in her adult life. In the scenario presented earlier, however, the child learns to question her own validity and thus feels insecure. She also learns to seek her father's love and support by pushing herself harder. As no child is perfect, there will be Other less than perfect academic and goal outcomes and therefore continued disappointments. As B. F. Skinner showed With his trainin Of rats intermittent atifi-
it's more), 8 weeks per year for 0 years, that's clinical decisions made. (How many of you perfectionists checked my math?) Now when you consider that we usually multitask and make clinical decisions outside of work as well, the number grows substantially. With this in mind, what is the likelihood that one of 300,000 decisions was the wrong one? The dean of the medical school at the University of Toronto once told his incoming class that "half ofwhat we teach you in the next 'l years is wrong, and the problenl is, we don't know which half." How can this be true? Medicine is always changing, and therefore what is "true" today may 44 MEDICINE This is judgmentalism, not often perceived as a positive quality. One way that this process becomes manifest is the seeking of socially significant goals, such as choosing career that is difficult to obtain, rigorous to live, socially admired, and financially rewarding. Sound familiar? This would be a less harsh, socially acceptable manifestation of the She also learns to seek her father' love and support by pushing herself harder. As no child is perfect, there will be other less than perfect academic and goal outcomes and therefore continued disappointments. As B. F. Skinner showed With his training Of rats, intermittent gratifi- cation is the strongest way of facilitating reward- seeking behavior. This child will become an adult who pushes herself hard toward perfection and rarely, if ever, is satisfied with her performance. This will adversely affect her adult relationships because she, too, will expect perfection of others and be critical of their performance. Copvri0htcxS ask questions and concede when you didn't have the answers. Not knowing was alright and encouraged. You presumed the adults had the answers. In your early teens you probably heard, "you are old enough to know better," This attitude was reinforced throughout your youth to the point of embarrassment if you did not know an answer. Medical training only made this worse. On
One way that this process becomes manifest is the seeking of socially significant goals, such as choosing a career that is difficult to obtain, rigorous to live, socially admired, and financially rewarding. Sound familiar? This would be a less harsh, socially acceptable manifestation of the drive to please. Many of us choose medicine to please our parents. 'Chis may be at a deep or subconscious level, but I ask you to consider this in your own choice of career. It is a lot of Work to have done to gain approval from your parents! Our parents are not the only ones whose approval we seek. We seek the approval of our mentors in our training and even our patients. In a simplistic way we want to be perceived as perfect. If perfection were obtainable, this might be a good goal; however, as we all make mistakes, none of us will ever achieve perfection, and many of us will remain unsatisfied with our performance and ourselves. How sad. I would choose to be happily imperfect any day of the week; it's much less stressful. Just acknowledging your imperfection will be freeing for you. I am not saying that you should give up the concept Of "bettering" yourself. This would lead to stagnation. I ask that you accept that the goal is to be better, not perfect. If the goal is "perfect," you can't win! Keep in mind that trying to live up to others' expectations Of you is a way of allowing them to control your life. Many Of us came to this in our teen years—rebellion is the out You presumed the adulVs had the answers, In your early teens you probably heard, "you are old enough to know better," This attitude was reinforced throughout your youth to the point of embarrassment if you did not know an answer. Medical training only made this worse. On rounds or in morning report, it was unacceptable to not know an answer, and you were made to feel inadequate if you didn't know; thus, the generation of anxiety about not knowing the answer to any question asked of you. At this time in your life, learn to say, "l don't know, but if you'd like I can find out for you." You will feel less pressure and the people you serve will appreciate your integrity and your desire to serve them. Not a bad tradeoff for a little imperfection. The Need to Be Needed: Care Addiction Doc Lew Childre and Howard Martin, in their book, The Heart,Vfarh described a state of emotion being common among physicians as the State Of Overcare is caring run amok. When you care ror someone, it is energizing. When you are cared for, this too is energizing. However, When you overcare, it is energy depleting. Have you ever sat up at 3:00 AM worrying about a
expectations of you is a way of allowing them to control your life. Many of us camc to this in our teen years—rebellion is the outcome. Take back your personal power; choose your own goals, not those held by Others. Anything worth doing is worth doing half-assed. Rachael Naomi Remen, M D Other expectations we try to live up to may be social. For example, if you were married during your training, your spouse lived through a lot of difficult times. You may feel obligated to "pay back" the spouse With a nice house, car, travel, and so forth. Although this appears to be valid on a social level, it may not be working for you. If you feel overworked because you are trying to do good things for your family—to be the provider—you may want to ask them if they would prefer more income or more of your time. You may be shocked to find out that the time spent you is more important than a new car or vacation, but you won't know until you ask. You can't ask for a more honest authority than your kids. Perfectionism also leads us to judge ourselves harshly. This may be the most detrimental of all judgment. If we cannot achieve perfect outcomes, we tend to beat ourselves up for it. We become our harshest and most persistent critics. The problem is We don't know how to let go. We hold the be Copyfish However, when you overcare, it is energy depleting. Have you ever sat up at 3:00 AM worrying about a patient?s diagnosis or a treatment decision you've made? Docs this serve you or the patient? NO. It is draining. You Will have less energy the next day, and you will have done nothing to serve your patient. Your own fatigue may be a disservice to them. '1%is is overcare. The true emotional energy keeping you awake contains a of "rounds fear" and the question "Am I a good enough doctor?" Perfectionism in action! Not only do wc overcare, but wc are also addicted to being needed. We often get love from our patients in many forms. A patient Of my Wife recently called at 7:00 AM to tell her that his mother had made dumplings the night before and he wanted her to have some While they were fresh. Although 7:00 was not terribly convenient, the patient had gotten up early, before work, to bring the dumplings to my wife. Not knowing where we live, he called from the parking lot of a nearby market. Moments like this, When a patient says thanks and goes out of his way to show you appreciation, arc the "highs" we get as physicians. We feel valued, we feel like we are enough, and we feel loved. The problem is, that this is a form of intermittent gratification. We spend so much Of our day feeling undervalued that we look for the "love" from our patients and don't often get it. We are then led to extend ourselves
obligated to "pay back" the spouse with a nice house, car. travel, and so forth. Although this appears to be valid on a social level, it may not be working for you. If you because are trying to do good things for your family—to be the provider—you may want to ask them if they would prefer more income or more of your time. You may be shocked to find out that the time spent with you is more important than a new car or vacation, but you won't know until you ask. You can't ask for a more honest authority than your kids. Perfectionism also leads us to judge ourselves harshly. This may be the most detrimental of all judgment. If we Cannot achieve perfect outcomes, tend tn beat ourselves up for it. We become our harshest and most persistent critics. The problem is We don't know how to let go. We hold the belief that the more we push ourselves, the more likely we are to succeed in our goal toward perfection. As perfection is illusory, we will spend the rest of our days beating ourselves up. What a waste of time and energy! Learn 10 your imperfect. Learn from any you make. Apologize if needed, and move on. The inability to admit not knowing an answer is a learned behavior. As a young child, you Were encouraged to many forms. A patient of my wife recently called at 7:00 AV to tell her that his mother had made dumplings the night and he Wanted her to have While they Were fresh _ Although AM Was not terribly convenient, the patient had gotten up early, before work, to bring the dumplings to my wife. Not knowing where We live, he called from the parking lot Of a market. Moments like this, when a patient says thanks and goes out of his way to show you appreciation, are the "highs" we get as physicians. We feel valued, we feel like we are enough, and we feel loved. The problem is, that this is a form of intermittent gratification. We spend so much of oar day feeling undervalued that We 100k for the our patients and don't often get it. We are then led to extend ourselves and often spread ourselves too thin to be appreciated. In the language of the addiction world, this is codependency. You are so busy caring for others that you no longer take care of yourself. The solution to this way of being is one of the most tasks known humans, to to yourself enough to kncnv that you are enough. If you come close to this, "'u no longer need external validation to get your "highs."
Our Mental Well-Being Our learning and mental growth are critical to our survival. Physicians enjoy learning. We enjoy science. Allow yourself to cnioy learning again. Denying oursclvcs this opportunity Creates tension Causes a Sense Of Stagnation. Set aside one uninterrupted hour per week to read the literature. At a nunimum pu will decrease your guilt and the size of the pile your and you might a better clinician for it! In addition, allow yourself the time to learn about subjects outside of medicine. such as art, history, and music. This allows for an enhanced sense of personal growth and development. Another key to well-being is to learn to say "I don't know." We are taught, through adverse conditioning in residency, never to utter these words. but in these days
of massive information availability, you can't know everything, This is especially true in the realm of integrative and holistic medicine where the world literature is massive Of various degrees Of scientific rigidity and information is readily available on the Internet. What is healthy response? Tell your patients you will find out the answer for them. 1.00k up the information (the Internet great for this) and have a staff member e-mail or phone the patient. helps you avoid a lengthy followup call, and you learn something rlcW in the process. This is great patient service!
Our Spiritual Well-Being For many of us, a sense of spirituality becomes our energy source. In Frank's study of women physicians,' she found that those women who had a religious or spiritual life were happier in their work life than those who did not. Spirituality and religion are not always connected. In a simple way spirituality is a sense of connection with something greater than yourself. This can be your family, your community, your your The bottom line is that you do not perceive it "all" as being about you. This is where work of service in medicine can truly blossom. Medicine is, after all, service, not serving. For many integrative-holistic practitioners, spirituality is the one of the mainstays of their personal balance. This is often into our lives in Of religion, meditation, yoga, or other pursuits afwell-being. Others may feel that spirituality is not important to the patient or themselves. However, of people believe in a higher being, uf patients regard their spiritual and physical health as equally important, and of family practitioners belie.'e that spiritual well-being is a factor in health.o More than 800 studies worldwide have shown that when individuals have Sense Of spirituality religious they have better physical health outcomes compared with those who do •rival. not have these qualities in their lives: Irself
Connect with the People in your Life Deep connection with others leads to a greater sense of humanity and a richer sense of a "larger meaning," It also enhances the Support receive in and decreases the social isolation you may have been experiencing. Deep personal connection also improves your personal health' A sense of true connection With others, especially those whom you serve, takes you out of the mode of physician and
brings you to the level of human helping human. •II-ais state is where healing can begin for both of you. Only thing I that truly heals people is unconditional love. Elizabeth K Obie-Ross, M D is especially true at home. Don't answer the phone during meals (except when you are on call). Shut off your and When you are With your family. The world will not fall apart without you—you are not that essen tial! Remember to Love We and need to and be Remember how gratifying it is when a patient gives you sincere thanks or a gift for the work you've done. If give more love, you Will receive morc love. If you come from a loving home environment, the "little" things at work will Stay little. is not how you but put into the doing that matters. Mother Teresa
your Monthly Health Plan Log Shown in fig use it track health plan. Post it somewhere obvious so you keep track. List all activities, no matter how minimal—perfection is discouraged!
